Berwick DM. Not again! BMJ. 2001; 322:(7281)247-248

Teenager given wrong drug dies. 2001. (accessed 10 September 2020)

Global Enteral Device Supplier Association. Frequently asked questions neuraxial connectors (ISO 80369-6). 2015. (accessed 10 September 2020)

Holbrook J. The criminalisation of fatal medical mistakes. BMJ. 2003; 327:(7424)1118-1119

International Organization for Standardization. ISO 80369-3:2016. Small bore connectors for liquids and gases in healthcare applications—part 3: connectors for enteral applications. 2016a. (accessed 10 September 2020)

International Organization for Standardization. ISO 80369-6:2016. Small bore connectors for liquids and gases in healthcare applications—part 6: connectors for neuraxial applications. 2016b. (accessed 10 September 2020)

ISO/TC 210—IEC/SC 62D/Joint Working Group 4. Guideline for the implementation of medical products using small bore connectors specified in the ISO 80369 series. 2017. (accessed 10 September 2020)

To err is human. Building a safer health system. In: Kohn LT, Corrigan JM, Donaldson MS (eds). Washington DC: National Academy Press; 2000

NHS England. Commissioning for quality and innovation. 2020. (accessed 10 September 2020)

NHS Improvement, NHS England. Never events data. 2020. (accessed 10 September 2020)

NHS Improvement Patient Safety Team. Supporting information for alert on safe transition to NRFit (video). 2017. (accessed 10 September 2020)

National Patient Safety Agency. NPSA/2009/PSA004B. Safer spinal (intrathecal), epidural and regional devices—part B. 2009. (accessed 10 September 2020)

Doctor admits fatal blunder over cancer boy. 2003. (accessed 10 September 2020)

ISO 80369-6. Implementation of neuraxial/neural devices in the UK. 2016. (accessed 10 September 2020)

Changing practice for neuraxial applications using NRFit™ small-bore connectors to improve patient safety

25 February 2021
Volume 30 · Issue 4


Clinical staff always aim to offer the best care for their patients while striving to minimise the risk of errors. The worldwide adoption of the NRFit™ system for neuraxial and regional block procedures is a major step forward. This article discusses the history of neuraxial needles and the experience of a major teaching hospital in adopting non-luer equipment for neuraxial procedures. References are made to resources that are available for other hospitals in the process of implementing the change to the NRFit system, which should result in the reduction of harm to patients.

Health professionals make mistakes that can have a catastrophic impact on patients, but, as Kohn et al (2000) noted, ‘to err is human’. In the vast majority of cases, human errors are made by well intentioned, highly trained skilled personnel. The onus is on humans to design systems to ensure that patients are safe from accidental injury.

Misconnection or wrong route administration of drugs is an issue that dogs medical practice globally. The consequences of wrong route administration may be fatal instead of merely inconvenient or financially costly. The use of the same luer small-bore connectors, be they accessing the parenteral, enteral, or neuraxial system, has led to a number of ‘serious untoward incidents’ over the years. The International Organization for Standardization (ISO) has been developing specific connectors for each individual route. The first to be seen in UK hospitals, ISO 80369-3:2016 (ISO, 2016a), was the implementation of a unique connector and purple-themed administration system for all oral and enteral products, ENFitTM.

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